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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a ii 1601 E. HAZELTON AVE., STOCKTON, CA t. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describA—jrhis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations,&the San Joaquin Local Health District. (�'' Job Address k5' �. CO G 9A City r �Gy Lot Size PM Owner's Name eC Address � !/ Phone Contractor k u[f�'I(`" -' _Address _00-0 w. License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION`❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR-❑ ,. OTHER ❑ t. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications Public n '"� ' e of hGrout'"____... r7 _ Other f T Cl Delta Depth of1Grout Seal"" T" x. yP - I 1 Irrigation Apptox. Depth 1 1 Eastern Sutface Seal Installed by - Repair Work Done ❑ Type of Pump H.P 4""` ' " state Work Done_ Well Destruction ' ❑ Well Diameters,.' Sealing Material imp 50'j Depth t Filler.Material (Below,50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION ESTRUCTION 1 I.(No septic system permitted if public sewer is �. available within 200 feet.) Installation will serve: Residence✓ Commercial_t�Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ADO Water table-depth- -- -- — - SEPTIC TANK ❑ Type/Mfg Capacity �No- Compartments PKG, TREATMENT PLT. ❑ -.- Method of Disposal Distance [o-nearest: Well Foundation Property Line"" �O k 3S Total len th/size - LEACHING LINE t -„ ❑ No. & Length of Ii nes 9 FILTER ABED Distance to nearest: Well f Foundation_JCS— Property Line 46 1 ' SEEPAGE PITS I I Depth- Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di1trict. Home owner or licensed agent's signature certifies the following:'"I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I J�� certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r t The applicant must call f r alk re::;;Wit ons. Complete drawing on reverse side. .�// Signed X r - Title: '" r Date: 3o OR PARTMENT USE ONLY Application Accepted by Date (e G 0 Area 417Pit or Grout Inspection by C Date Final Inspection by. a Date.. �T Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95201 FEE "_ - INFO AMOUNT bUE'E AMOUNT REMITTED' CASH RECEIVED 8Y DATE YERiVIIT'NO. j r.EH 13-24(REV.1/x5) © F �• y + ' EH 14-2e I